Prior authorization for Medicare, Medicaid, and government payers

Government-payer PA covers traditional Medicare (minimal PA), Medicare Advantage (heavy PA), Managed Medicaid (state-by-state), CHIP, TRICARE (for the military community), VA Community Care (external VA care), and FEHB (federal employees). The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) reshapes much of this book starting in 2026.

Traditional Medicare (Parts A, B, D)

Traditional Medicare has minimal PA by design. Part A (inpatient, SNF, home health, hospice) and Part B (outpatient, physician, DME) largely do not require PA for most services. CMS has introduced PA on select DMEPOS (certain power wheelchairs, pressure-reducing support surfaces) and added prior authorization for certain hospital outpatient department services starting 2020 (specific blepharoplasty, botulinum toxin for upper-face, panniculectomy, rhinoplasty, vein ablation). Medicare Advantage operates differently (see below).

Part D prescription drug coverage involves PA at the PBM level for formulary-excluded drugs, step therapy, and quantity limits. Part D PA is entirely PBM-based (CVS Caremark, OptumRx, Express Scripts, Humana Rx).

Medicare Advantage plans

Over 50 percent of Medicare-eligible beneficiaries are now enrolled in Medicare Advantage. MA plans must not impose coverage criteria more restrictive than traditional Medicare (per CMS-4201-F, 2024), but they still apply PA broadly. Major MA plans: UHC Medicare Advantage (largest), Humana MA, Aetna MA, Anthem BCBS MA (by state), Cigna MA (where available), Kaiser Senior Advantage, WellCare, Centene Ascension MA, and dozens of regional and state-specific MA plans. Each has its own PA delegation.

Post-acute MA PA is covered separately at post-acute PA and is the most-scrutinized category. Specialty services follow standard delegate patterns (eviCore, Carelon, Optum, NIA).

Managed Medicaid plans

Most states run Medicaid through Managed Care Organizations (MCOs). National Managed Medicaid players: Centene (dominant in many states under various brand names including Sunshine Health FL, Meridian IL, Peach State GA, WellCare across multiple states), Molina Healthcare (CA, OH, NM, TX, WA, FL), WellCare (owned by Centene), Aetna Better Health, UHC Community Plan, Anthem Medicaid (under Amerigroup and Healthy Blue), Humana Healthy Horizons. Each state Medicaid plan has state-specific PA rules overlaid on the MCO\u2019s corporate policies.

CHIP (Children\u2019s Health Insurance Program)

CHIP operates as a state program often administered by the same MCOs that handle Managed Medicaid. Coverage and PA rules generally follow state Medicaid but with different benefit structures for children. EPSDT requirements expand pediatric coverage.

TRICARE

TRICARE serves active-duty military, retirees, and dependents. Administered by region: TRICARE East (Humana Military), TRICARE West (HealthNet Federal Services - transitioning to TriWest in 2024-2026), TRICARE Overseas. PA is required for most specialty services, certain imaging, and many medications. TRICARE\u2019s TRICARE For Life is the supplement for Medicare-eligible military retirees.

VA Community Care Network

The VA\u2019s Community Care Network (CCN) is administered by Optum for Regions 1-3 and TriWest for Regions 4-5. Community Care allows Veterans to receive care outside VA facilities when clinical or geographic criteria are met. PA/referral from the VA is required before community care. Optum CCN and TriWest each have their own portals and authorization processes. VA-specific documentation (VA 10-7079 form equivalents, referral documentation) is required.

FEHB (Federal Employees Health Benefits)

FEHB is the health insurance program for federal employees, retirees, and dependents. BCBS Federal Employee Program (FEP), GEHA, APWU, and several other carriers participate. BCBS FEP is administered across the BCBS federation similar to commercial BCBS but with FEP-specific benefits. See BCBS plans for the federation detail.

CMS-0057-F Interoperability and Prior Authorization Final Rule

The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) applies to Medicare Advantage, Medicaid, CHIP, and QHP issuers on the federal exchange. Key requirements: 72-hour urgent PA turnaround and 7-day standard PA turnaround starting in 2026; specific denial reason sharing; public reporting of PA metrics; and a FHIR-based Prior Authorization API by January 2027 to automate PA submission. The rule accelerates the shift from portal-based PA to API-based PA for impacted payers.

Commercial payers are not directly covered, so portal and phone workflows will continue for commercial PAs for the foreseeable future. A stack that only speaks FHIR will strand commercial volume; a stack that only operates portals will miss the efficiency gains the rule unlocks on MA and Medicaid.

How Flexbone handles government-payer PA

Flexbone routes government-payer PA through the correct channel: Medicare traditional claim submission with PA only where required, MA plan delegation map for each plan (Humana to eviCore/HealthHelp, UHC MA to Optum/internal, Aetna MA to eviCore, Anthem MA to Carelon), Managed Medicaid MCO-specific portals, TRICARE through Humana Military or HealthNet/TriWest, VA CCN through Optum or TriWest, and FEHB through the BCBS federation or other FEHB carrier. See commercial payers for delegation detail that often overlaps with MA.